High frequency-low morbidity mechanical complications of tube feeding: a prospective study

Enteral nutrition in intensive care patients: a practical approach. Working Group on Nutrition and Metabolism, ESICM. European Society of Intensive Care Medicine

Severe protein-calorie malnutrition is a major problem in many intensive care (ICU) patients, due to the increased catabolic state often associated with acute severe illness and the frequent presence of prior chronic wasting conditions. Nutritional support is thus an important part of the management of these patients. Over the years, enteral nutrition (EN) has gained considerable popularity, due to its favorable effects on the digestive tract and its lower cost and rate of complications compared to parenteral nutrition. However, clinicians caring for ICU patients are often faced with contradictory data and difficult decisions when having to determine the optimal timing and modalities of EN administration, estimation of patient requirements, and choice of formulas. The purpose of this paper is to provide practical guidelines on these various aspects of enteral nutritional support, based on presently available evidence.

Nutritional management of patients with gastrointestinal fistulas

Nutritional support plays a key and integral role in the management of patients with gastrointestinal fistulas. It needs to be instituted early to minimize erosion of body cell mass, to prevent further physiologic deterioration of the patient, and to initiate repletion in an otherwise malnourished patient. Furthermore, it allows for rest of the gastrointestinal tract and facilitates healing of the fistula.

Audit of nutritional support provided to surgical patients by a nutrition team

An audit was carried out over a 24 month period to assess the practice, safety and efficacy of nutritional support provided to surgical patients by a designated team. 135 patients received nutritional support: 51% were fed parenterally, 32% enterally and 17% via combined nutritional support. The duration of feeding ranged from 1-177 days with 23% being supported for < 7 days. The line infection rate for patients receiving intravenous nutrition was 6.5%. Nutritional outcome was assessed using weight, anthropometry and bioelectrical impedance analysis. Pre-and post-feeding results were available for 67% of patients. These patients were classified as either oedematous (n = 21), normally nourished (n = 23) or nutritionally depleted (n = 46). Overall, the oedematous patients lost water, the protein status of the normally nourished group deteriorated slightly and the nutritional status of the nutritionally depleted patients was maintained. Audit is a valuable means of defining the efficacy of a nutrition support service and has identified areas which require review.

Feeding tubes in endoscopic and clinical practice: the longer the better?

In an attempt to combine successful distal feeding tube positioning and a more prolonged stay without interfering with tube patency and feeding regimens, commercially available 105-cm polyurethane feeding tubes were compared with experimental tubes 125 cm and 145 cm long. The technique for endoscopic positioning at the bedside of the patient was standardized. Forty-five patients who required intraduodenal or intrajejunal enteral feeding in the intensive care unit were randomly assigned to one of the three tube-length groups. Even the 105-cm short feeding tubes were able to be introduced beyond the duodenojejunal junction, although insufficient tube length remained for tube fixation at the nose. The longer variants, however, were positioned significantly (p < 0.01) deeper in the intestine, with enough spare tube length for slack formation in the stomach and fixation at the nose. Tubes were electively removed in 29% of the patients. Irrespective of tube length, premature removal by the patient (in 36%) or by the nurse (in 11%) was rather high. Tube blockage was irremediable in 9%. Feeding tubes survived on average 10.6 days in all three tube-length groups, despite the fact that many drugs were administered by tube as well. The successful, easy, and fast endoscopic positioning of feeding tubes far into the intestine and at the patient's bedside may further expand the possibility for enteral feeding. Moreover, polyurethane materials are well tolerated, and increasing the tube length does not interfere with tube patency or feeding plans.